Jfournal of medical ethics, 1992, 18, 94-98WordsA proposal to classify happiness as apsychiatric disorderRichard P Bentall Liverpool UniversityAuthors abstract definition of happiness. However, despite the fact that formal diagnostic criteria have yet to be agreed, itIt is proposed that happiness be classified as a psychiatric seems likely that happiness has affective, cognitive anddisorder and be included in future editions of the major behavioural components. Thus, happiness is usuallydiagnostic manuals under the new name: major affective characterised by a positive mood, sometimes describeddisorder, pleasant type. In a review of the relevant as elation or joy, although this may be relativelyliterature it is shown that happiness is statistically absent in the milder happy states, sometimes termedabnormal, consists of a discrete cluster of symptoms, is contentment. Argyle, in his review of the relevantassociated with a range of cognitive abnonnalities, and empirical literature, focuses more on the cognitiveprobably reflects the abnormal functioning of the central components of happiness, which he describes in termsnervous system. One possible objection to this proposal of a general satisfaction with specific areas of life suchremains - that happiness is not negatively valued. as relationships and work, and also in terms of theHowever, this objection is dismissed as scientifically happy persons belief in his or her own competence andirrelevant. self-efficacy. The behavioural components ofIntroduction happiness are less easily characterised but particular facial expressions such as smiling have been noted;Happiness is a phenomenon that has received very interestingly there is evidence that these expressionslittle attention from psychopathologists, perhaps are common across cultures, which suggests that theybecause it is not normally regarded as a cause for may be biological in origin (2). Uncontrolledtherapeutic concern. For this reason, research on the observations, such as those found in plays and novels,topic of happiness has been rather limited and any suggest that happy people are often carefree,statement of existing knowledge about the impulsive and unpredictable in their actions. Certainphenomenon must therefore be supplemented by kinds of social behaviour have also been reported touncontrolled clinical observation. Nonetheless, I will accompany happiness, including a high frequency ofargue that there is a prima facie case for classifying recreational interpersonal contacts, and prosocialhappiness as a psychiatric disorder, suitable for actions towards others identified as less happy (3). Thisinclusion in future revisions of diagnostic manuals latter observation may help to explain the persistencesuch as the American Psychiatric Associations of happiness despite its debilitating consequences (toDiagnostic and Statistical Manual or the World Health be described below): happy people seem to wish toOrganisations International Classification of Diseases. force their condition on their unhappy companions andI am aware that this proposal is counter-intuitive and relatives. In the absence of well-establishedlikely to be resisted by the psychological and physiological markers of happiness, it seems likely thatpsychiatric community. However, such resistance will the subjective mood state will continue to be the mosthave to explain the relative security of happiness as a widely recognised indicator of the condition. Indeed,psychiatric disorder as compared with less secure, Argyle has remarked that If people say they are happythough established conditions such as schizophrenia. then they are happy (4). In this regard, the rules forIn anticipation of the likely resistance to my proposal I identifying happiness are remarkably similar to thosewill therefore preface my arguments with a brief review used by psychiatrists to identify many other disorders,of the existing scientific literature on happiness. Much for example depression.of the following account is based on the work of Argyle The epidemiology of happiness has hardly been(1). researched. Although it seems likely that happiness is It is perhaps premature to attempt an exact a relatively rare phenomenon, exact incidence rates must depend on the criteria for happiness employed inKey words any particular survey. (In this respect happiness is also not unique: similar problems have been encounteredHappiness; major affective disorders; psychiatry. when attempts have been made to investigate the
Richard P Bentall 95epidemiology of other psychiatric disorders such as by a rapid remission of symptoms, and endogenousschizophrenia (5)). Thus, although Warr and Payne (6) happiness which may have a relatively chronic onsetfound that as many as 25 per cent of a British sample and which may be less often followed by symptomaticsaid that they were very pleased with things improvement. The differential diagnosis of these twoyesterday, Andrews and Withey (7), studying a large types of happiness is an obvious project for futureUS sample, found that only 5.5 per cent of their studies. Given the apparent similarities betweensubjects rated themselves as scoring maximum on a happiness and depression, it seems possible thatnine-point scale of life-satisfaction. One problem with endogenous happiness will be characterised by positivethese kinds of data is that they have been generated in mood first thing in the morning, a heavy appetite, andthe absence of good operational criteria for happiness persistent erotomania.and have focused on the cognitive components of thecondition (perhaps because these are comparatively Happiness as a psychiatric diseaseeasy to measure) rather than the affective and Since the emergence of the profession of psychiatry inbehavioural components. It is therefore quite possible the nineteenth century it has commonly been assumedthat informal observation is a better guide to the that psychiatric disorders are forms of disease. Whilstprevalence of happiness in community samples. this assumption has not gone unchallenged in recentCertainly, if television soap operas in any way reflect years (14) it remains so pervasive within the mentalreal life, happiness is a very rare phenomenon indeed in health professions that the demonstration thatplaces as far apart as Manchester, the East End of happiness qualifies as a disease would be a powerfulLondon and Australia. Interestingly, despite all the argument for including it within future nosologies ofuncertainty about the epidemiology of happiness, psychiatric disorder.there is some evidence that it is unevenly distributed Historically, there have been two approachesamongst the social classes: individuals in the higher towards the definition of disease (15). The first, whichsocio-economic groupings generally report greater is best exemplified by the work of the doctor Thomaspositive affect (8) which may reflect the fact that they Sydenham in the eighteenth century, involves theare more frequently exposed to environmental risk- identification of syndromes consisting of clusters offactors for happiness. symptoms that occur together. The second, which is Further light might be shed on the nature of best exemplified by the later work of Virchow, involveshappiness by considering its aetiology. Although the the identification of a pathological process that iscause or causes of happiness have yet to be identified causally implicated in a disturbance of body oraetiological theories have implicated both behaviour. In practice, medical scientists usually hopeenvironmental and biological factors. With respect to that the two types of classification will converge tothe environment, there seems little doubt that discrete enable the generation of causal models of disease.episodes of happiness typically follow positive life- However, for most psychiatric disorders this prospectevents (9). However, the observation that some people lies somewhere in the future (16). For this reason,are generally happier than others suggests that less when considering the evidence that happiness is atransient factors may also play an important role. disease, it will be useful to bear in mind for comparisonWhile it has been suggested that a general disposition the evidence pertaining to the disease status oftowards happiness is related to self-esteem (10) and recognised psychiatric disorders such associal skills (1), two variables which presumably reflect schizophrenia.early learning experiences, the finding that The question of whether or not it is possible toextroversion is a good predictor of happiness even identify a meaningful syndrome of happiness has beenyears in the future (1 1) suggests that biological factors the subject of only very limited research. According tomay be implicated. Argyle (1), most investigators agree that happiness is Evidence that happiness is related to cognitive best thought of as a dimension of affect, rather than asabnormalities will be outlined below when I discuss the a discrete category of emotional disequilibrium: in thisproposition that happiness is irrational. Genetic respect at least happiness appears to be similar to bothstudies of happiness are a neglected avenue of research schizophrenia and perhaps the majority of psychiatricbut neurophysiological evidence points to the disorders (17). However, the relationship between theinvolvement of certain brain centres and biochemical dimension of happiness and other affective dimensionssystems. Thus, stimulation of various brain regions has remains unclear. Thus, in a factor-analyticbeen found to elicit the affective and behavioural investigation (8) it was observed that reports ofcomponents of happiness in animals (12) as has the happiness and reports of negatively valued affectiveadministration of drugs which affect the central states loaded on separate factors, suggesting that theynervous system such as amphetamine and alcohol (13). are independent of each other. Interestingly, peopleTaking the environmental and biological evidence who report high-intensities of happiness also reporttogether it may be necessary to discriminate between high intensities of other emotions (18), which might bevarious different types of happiness. Thus, it may be regarded as evidence for the hypothesis (to beuseful to distinguish between reactive happiness, discussed below) that happiness is related to ausually manifesting itself as an acute episode followed neurophysiological state of disinhibition. Nonetheless,
96 Words: A proposal to classify happiness as a psychiatric disorderthe frequencies with which people report happiness and (Julius Caesar, for example, is reputed to have askedthe negatively valued affective states appear to be for the company of fat men on these grounds (24)).negatively correlated (19). Some confusion also exists Given the well-established link between both alcoholabout the relationship between happiness and the and obesity and life-threatening illnesses it seemspsychiatric disorder of mania; although it might be reasonable to assume that happiness poses a moderateexpected that these are related conditions Argyle (1) risk to life. The common observation that happinesshas noted that mania, in contrast to happiness, is leads to impulsive behaviour is a further cause formainly characterised by excitement. Nonetheless, the concern.diagnostic criteria for hypomanic episodes employed More clear evidence that happiness confers aby the American Psychiatric Association (20) seem to biological disadvantage can be discerned from theallow happiness to be regarded as a subtype of literature relating various cognitive measures to moodhypomania. Taking all this evidence together, it might state, but before discussing this evidence it will first bebe argued that there is only modest empirical support useful to consider the proposition, advocated by somefor the notion of a discrete happiness syndrome. On the philosophers, that irrationality rather than disease beother hand, the evidence is really quite favourable considered the criterion for psychiatric disorder.when compared with the evidence supporting otherwidely accepted psychiatric syndromes such as Happiness, irrationality and cognitionschizophrenia (21). Mainly because of persisting doubts about the value of Some evidence that happiness is related to a applying the concept of disease to psychiatricdisturbance of the central nervous system has already disorders, a number of philosophers have suggestedbeen noted. Just as it is possible to elicit schizophrenic that the quality of rationality is the most appropriatesymptoms in some individuals by stimulating the criterion for distinguishing between such disordersparietal lobes, so too it is possible to produce happiness and types of behaviour and experience not worthy ofby brain stimulation, though of subcortical centres psychiatric attention. According to Radden (26),(12). Cortical centres also seem to be implicated behaviour may be described as irrational if it is bizarrehowever, as both left hemisphere seizures and right and socially unacceptable, reduces the individualshemispherectomy have been associated with prolonged expected utilities, or is not grounded on good (ieeuphoric states; indeed it has been suggested that logically consistent and acceptable) reasons; in theemotional states in general are regulated by a complex latter case, in particular, Radden believes that thebalance of excitatory and inhibitory centres in both behaviour should be the subject of psychiatrichemispheres, and that abnormal affective states of any scrutiny. A similar view has been taken by Edwardskind reflect a disturbance of this balance (22). Clearly, (27) who claims that bona fide cases of psychiatricfurther biological research is needed to specify in any disorder are characterised by actions that fail to realisedetail the role of neuropsychological abnormalities in manifest goals, thinking that is illogical and repletehappiness but a promising start has been made, and with contradictions, beliefs that should be falsified byquite a clear picture is apparent in comparison to the experience, the inability to give reasons for actions,mixed results of nearly one hundred years of research unintelligible or nonsensical thinking, and a lack ofinto schizophrenia (21). impartiality and fairmindedness. Indeed, it is the lack of progress in identifying a Some definitions of irrationality clearly make more biological pathology for schizophrenia and other sense than others. Bizarreness and social disapprovalpsychiatric disorders that has led some authors to reject are weak criteria for irrationality because they are the notion that schizophrenia is a disease (14) and culturally constrained and difficult to apply with anyothers to argue that the criteria for disease should not consistency: the Lancastrians predilection for driedrequire the identification of an underlying biological pigs blood may seem bizarre to the Hotentot, whopathology (23). Clearly, if, as I have argued, happiness prefers to eat slugs. Against this, some authors havemeets the narrower criteria for disease employed in argued that delusional beliefs should be tested againstphysical medicine it is also likely to meet any such their cultural background, although this has thebroader criteria advocated for psychiatry. For disadvantage of allowing totalitarian regimes toexample, it has been suggested that, for the purposes of diagnose political dissidents as insane (28).psychiatric research, a disease be simply regarded as In testing whether or not happiness is irrational itany deviation from the norm by way of excess or deficit may therefore be safer to fall back on the otherwhich confers upon the sufferer some form of approaches to defining irrationality outlined bybiological disadvantage (24). Evidence that happiness Radden and Edwards. Thus, although there is a lack ofis statistically abnormal has already been discussed relevant data, it seems reasonable to assume thatand, despite the lack of clear data, there is at least some happiness often results in actions which fail to realisereason to suppose that happiness confers a biological manifest goals, and which therefore decrease the happydisadvantage, at least in the short term. Consistent persons expected utilities. The potentially life-clinical evidence of an association between happiness, threatening consequences of happiness have alreadyobesity and indulgence in alcoholic beverages has been discussed. In addition, happy people mayexisted from before the time of scientific medicine experience great difficulties when faced with mundane
Richard P Bentall 97but essential tasks. (to name but three unequivocal examples of disease Both Radden and Edwards imply that irrationality described only in recent times) were not diseases beforemay be demonstrated by the detection of cognitive their discovery. In any event, once the debilitatingdeficits and distortions of one sort or another. There is consequences of happiness become widely recognisedexcellent experimental evidence that happy people are it is likely that psychiatrists will begin to deviseirrational in this sense. It has been shown that happy treatments for the condition and we can expect thepeople, in comparison with people who are miserable emergence of happiness clinics and anti-happinessor depressed, are impaired when retrieving negative medications in the not too distant future.events from long-term memory (29). Happy people The second, related objection to the proposal thathave also been shown to exhibit various biases of happiness be regarded as a psychiatric disorder pointsjudgement that prevent them from acquiring a realistic to the fact that happiness is not normally negativelyunderstanding of their physical and social valued. Indeed, it is testimony to the insidious effectsenvironment. Thus, there is consistent evidence that of happiness on some of the greatest minds in historyhappy people overestimate their control over that some philosophers have argued that the pursuit ofenvironmental events (often to the point of perceiving happiness is the ultimate aim of all human endeavours.completely random events as subject to their will), give However, it is notable that even some of those whounrealistically positive evaluations of their own have been rash enough to advocate the greatestachievements, believe that others share their happiness for the greatest number have been explicit inunrealistic opinions about themselves, and show a rejecting those extreme forms of happiness associatedgeneral lack of evenhandedness when comparing with gluttony of the senses (32). More importantly, thethemselves to others (30). Although the lack of these argument that happiness be excluded from futurebiases in depressed people has led many psychiatric classifications of mental disorder merely on theresearchers to focus their attention on what has come to grounds that it is not negatively valued carries thebe known as depressive realism it is the unrealism of implication that value judgements should determinehappy people that is more noteworthy, and surely clear our approach to psychiatric classification. Such aevidence that such people should be regarded as suggestion is clearly inimical to the spirit ofpsychiatrically disordered. psychopathology considered as a natural science. Indeed, only a psychopathology that openly declaresPossible objections the relevance of values to classification could persist inI have argued that happiness meets all reasonable excluding happiness from the psychiatric disorders.criteria for a psychiatric disorder. It is statisticallyabnormal, consists of a discrete cluster of symptoms, Richard P Bentall is Senior Lecturer in the Department ofthere is at least some evidence that it reflects the Clinical PsycholoV, Liverpool University.abnormal functioning of the central nervous system,and it is associated with various cognitiveabnormalities - in particular, a lack of contact with Referencesreality. Acceptance of these arguments leads to theobvious conclusion that happiness should be included (1) Argyle M. The psycholoV of happiness. London:in future taxonomies of mental illness, probably as a (2) Methuen, 1987.I. Ethology: the biology of behaviour. New Eibl-Eibesfeldtform of affective disorder. This would place it on Axis York: Holt, Rinehart and Winston, 1975.I of the American Psychiatric Associations Diagnostic (3) Andrews F M, Withey S B. Social indicators of well-and Statistical Manual (20). With this prospect in being. 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